Payers use data to flag those at greatest risk of opioid abuse

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While most headline-grabbing solutions to ease the opioid crisis focus on reducing prescriptions and getting people help after they become addicted, a growing movement seeks to catch people before they fall into opioid addiction.

Providers, payers and community groups are coming together using principles of population health — namely social determinants of health (SDOH) data — to find at-risk people. The stakeholders share data on factors like poverty rates and transportation availability to spot potential problems before they spiral out of control. And there is some evidence the programs work and save money.

"That combination of data helps you flag who are higher-risk cases," said Rosemarie Day, president of Day Health Strategies and former chief operating officer at MassHealth, Massachusetts' Medicaid program, in an interview.

Payers like Aetna, Anthem and Cigna have implemented programs and set goals to reduce opioid prescriptions and move people to other types of pain management. The American Medical Association (AMA), on the other hand, backs medication-assisted treatment. MAT uses medications, counseling and behavioral therapies to treat opioid use disorders.

Instead, the opioid problem is often fueled by economic and social upheaval. Poverty and substance use problems "operate synergistically, at the extreme reinforced by psychiatric disorders and unstable housing," according to the report.

"While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and other substances," the report stated.

"Addiction can cause and prolong homelessness, and the experience of homelessness complicates one's ability to engage in treatment," according to the 2017 report.

Creating SDOH programs

Parkland Health & Hospital System in Dallas is one healthcare organization working beyond its four walls. The safety net hospital, with a high percentage of Medicaid patients and uncompensated care, created the Parkland Center for Clinical Innovation (PCCI). It's essentially an analytics unit of data scientists and healthcare professionals using SDOH, encounter data, claims data and analytics.

The group's Health Information Portal allows the health system to connect physicians and case managers with social services groups in the area for greater care coordination.

Parkland works with more than 90 community groups, including housing assistance, homeless groups, education and transportation, in the Dallas-Fort Worth area through its portal. More than 200,000 people have been helped and about one million services provided.

PCCI CEO Steve Miff said in an interview the key to handling SDOH and vulnerable populations is to leverage community programs and resources. Integrating community-based resources expands the support network, helping patients at multiple touch points across the community.

PCCI uses an analytics and predictive modeling system to scan every Parkland facility patient. The predictive modeling system takes into account SDOH, socioeconomics, medical conditions, medications, housing, health status and healthcare utilization information. These data are used to gauge a person's risks, including for opioid addiction.

Parkland lets patients opt into the system and decide the level of information they are comfortable sharing with stakeholders. Some may only want to provide basic demographics and personal information, while others may allow specific medical and mental health information. The platform is HIPAA-secured and multiple user roles offer information depending on the individual.

This helps protect a patient's privacy and not allow volunteers in community groups to get personal medical information.

The system alerts stakeholders, such as a pharmacy team, a health plan, a case manager or a primary care physician, if there's a problem. Alerting the entire care system and community support team means whichever touch point the patient goes to can address the issue during the next interaction, whether that's a doctor's appointment, a pharmacist or a visit to a homeless shelter.

The stakeholder can alert the person to the potential issue and either counsel the individual or forward the person to the right expert depending on the alert. "All of those pieces are needed to come into place if you're really going to make a difference and drive something that's sustainable," Miff said.

Miff added that the program has significantly reduced the number of adverse drug events, reduced readmissions and saved money.

PCCI's programs have saved between $30 million and $40 million over the past four years, he said.

Getting buy-in

The first step to getting community group buy-in was creating a comprehensive community assessment to address groups' needs and their capabilities and workflows.

PCCI then created a system to work within the community groups' workflows. "It needs to be easy. It needs to sit in their workflows and it needs to fit the unique services that they provide," Miff said.

On the provider side, PCCI needed to address a pain point. Namely, it created a network that would allow providers to refer patients immediately for services and not have multiple hoops and screens to scroll through. PCCI educated providers on the benefits and integrated the system into the existing workflow at the point of care.

Parkland is also planning a program to help people recently released from prison, aiming to tackle risk factors like mental health and substance abuse, as well as offer housing, transportation and job training.

PCCI hopes to expand further with a goal of 300 community-based organizations being part of the network by the end of the year. That's triple the current number. PCCI is also hoping to spread beyond the Dallas-Fort Worth area so it can share analytics, workflow and best practices to others outside of the area.

Medicaid can play a critical role

Since Medicaid is often the payer for people most at-risk, Medicaid managed care organizations collect data that could be integrated with provider encounter data to get a well-rounded look at a patient, according to a recent National Quality Forum report​.

Medicaid also plays a role in opioid addiction treatment. Nearly four in ten non-elderly adults with opioid addiction are covered by Medicaid. Adults with Medicaid are more likely than others to receive substance abuse disorder treatment, Kaiser Family Foundation said.

A new report from the group promoted Medicaid as a 'linchpin' for states to address the opioid epidemic.

Medicaid provides access to prevention, treatment and recovery services. Medicaid also has "a structured system of accountability for providers, multiple touch points in healthcare and data systems to identify those with addiction."

Mass ACO

A new Medicaid accountable care organization in Massachusetts may take the collaboration between providers, payers and community groups a step further.

The new ACO in MassHealth received federal government funding of $1.8 billion to restructure the commonwealth's Medicaid program via a five-year 1115 waiver, created under the Affordable Care Act to test new models.

The ACO kicked off March 1 with more than 850,000 MassHealth members. Seventeen healthcare organizations are in the Massachusetts ACO, including Partners HealthCare, Beth Israel Deaconess and Lahey Health on the provider side and Tufts Health Public Plans, Fallon Community Health Plan and Neighborhood Health Plan on the payer side.

Massachusetts was the first state in the nation in October 2016 to create a payment model that added SDOH variables to medical diagnoses, age and sex. This new project addresses SDOH and includes community partners to help providers and payers work with patients beyond the healthcare offices.

The ACO project will allow for participants to marry the claims data that Medicaid collects with Medicaid managed care payers and provider information that's found on electronic health records and during a provider's upfront patient assessment. Payers can take that data and flag providers of patients with possible higher risks.

Those who are higher risk of opioid addiction could be placed with a specialist in the community. Day said community-based recovery coaches will play a vital role on both the treatment and prevention sides. She added that the coaches' job description will expand to include using SDOH data to prevent someone who is at-risk of falling into opioid addiction.

These kinds of programs address "upstream factors of addiction" that go beyond treatment after someone becomes addicted, she said.

The ACA's Medicaid expansion allows states to expand eligible Medicaid enrollees to those with incomes of 400% of the federal poverty level. Eighteen states have not expanded Medicaid. ​

The expansion "has been a really important factor in states in covering people who are addicted," Boozang said.

Some of the non-expansion states may decide to pursue limited and partial expansions with state funds to help combat the opioid crisis, Boozang speculated.

"There's no question that expansion can be an important component to cover people with addition," she said.